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With health care reform here to stay, it's important to understand what model of health care delivery system will likely emerge—and how we will get there.
Today, we have a health care system that is reimbursed based on activity rather than positive results. It is set up to care for patients reactively when they are sick or injured, with little financial incentive or accountability to promote a patient's or community's health or to manage care efficiently.
Consider this example: If a patient is admitted to a hospital for congestive heart failure, is treated and sent home, but then is readmitted because his post-hospital condition was not closely monitored or recovery instructions were not followed, the hospital gets paid for both inpatient visits, even though the second visit could have been prevented. Ironically, what the hospital is not compensated for today is the vital in-home care management that could have prevented the readmission—and would have been far less expensive.
Given this reality, it's not hard to understand why a recent Institute of Medicine study found that $750 billion or 30 percent of our nation's health care spending is wasted each year on unnecessary care. And why we have a population that is plagued by costly, yet preventable, health conditions.
As we look to the future, the U.S. health care system must shift from a reactive, disease- and illness-centered model to one that rewards patient-centered care focused on health, wellness and prevention. Providers can no longer be paid solely for services rendered. Instead, they must ensure that services provided are medically necessary, that care delivered is the safest and most effective possible, that patient care is managed to encourage prevention and adherence to treatment plans, and that the cost of care (including prescriptions) represents the most economical options.
Providers will also need to make their costs, quality ratings and patient satisfaction scores easily accessible to the public. This will enable consumers to compare options effectively and make informed health care decisions, just as they do for other significant purchases.
With consumers increasingly being covered by high-deductible health insurance plans, this type of informed decision-making will become the norm—radically changing the health care marketplace and putting the purchasing power in the hands of consumers, where it belongs. According to the Rochester Business Alliance's 2011 Health Benefits Survey, 46 percent of employers offered high-deductible insurance options in 2011—up from just 15 percent in 2009-and the percentage is expected to continue to climb dramatically.
Through health care reform legislation, Medicaid and Medicare have begun this paradigm shift. Compliance measures at the state and federal level will increasingly reward or penalize providers based on their performance tied to safety, clinical results, health and wellness, patient satisfaction and cost. However, Medicaid and Medicare alone cannot drive the kind of systemic change required to reshape and sustain a patient-centered health care model that fosters improved health, efficiency and the highest standards of clinical care. This requires innovation and leadership from local health care systems around the country in partnership with private insurers, employers, physicians and, yes, patients too.
An example in our community is the Accountable Care Partnership, newly formed between Rochester General Health System and the Greater Rochester Independent Practice Association. Consisting of 900 employed and private practice physicians, it is the only partnership of its kind in our area.
As the Rochester Business Journal reported several weeks ago, RGHS and GRIPA have entered into an innovative agreement with Excellus BlueCross BlueShield that begins on Jan. 1. This partnership will improve the health of our community and help control the spiraling cost of health care by creating a continuum of care accountable for delivering high-quality, cost-effective results to both the patient and the partnership. Expect similar accountable care programs to be established throughout our community in the future.
For nearly two decades, Rochester has pioneered payment reform and cost control by taking a community-based approach to managing population health. In the 1990s, this innovative and collaborative leadership model resulted in health care rates that were more than 30 percent below the national average and 45 percent lower than the rest of New York. Today's imperative for transformative change provides yet another watershed opportunity for Rochester to boldly shape the health care system of the future.
Mark C. Clement is Rochester General Health System president and CEO. This is the second of four articles examining health care reform that will appear over the next several months.
12/21/12 (c) 2012 Rochester Business Journal. To obtain permission to reprint this article, call 585-546-8303 or email email@example.com.